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Based on observation the facility failed to provide corridor doors that would close and resist the passage of smoke in accordance with the LSC section 19.3.6.3.

Findings include:

1. On 4/20/10 at approximately 1:16 PM during an inspection of the facility with maintenance staff, the following observation was made:

a. Room 2-068 corridor door handle stuck in the open position and would not provide a positive latch when the door was closed.

Based on observation the facility failed to provide for the protection of hazardous areas in accordance with the LSC section 19.3.2.1.

Findings include:

1. On 4/20/10 between approximately 1:32 PM and 1:43 PM during an inspection of the facility with maintenance staff, the following observations were made:

a. At approximately 1:32 PM, Room 2-106A was observed to have been converted to a Storage Room. This room is now required to meet the standards for hazardous areas. The wall above the door, on the right side of the room has an open penetration where drywall has been cut away.

b. At approximately 1:43 PM, Room 1-049 corridor door was observed not to self-close to a positive latch.

Based on observation the facility failed to provide approved means of egress in accordance with the LSC section 19.2.2.3, 19.2.2.4.

Findings include:

1. On 4/20/10 between approximately 3:35 PM and 3:53 PM during an inspection of the facility with maintenance staff, the following observations were made:

a. At approximately 3:35 PM, the Stair #4 Ground Level door latching mechanism failed to provide a positive latch when closed.

b. At approximately 3:53 PM, the Central Supply exterior exit door required excessive force to open.

Based on observation the facility failed to provide lighting in accordance with the LSC section 19.2.8.

Findings include:

1. On 4/20/10 between approximately 10:00 AM and 12:00 PM during a review of records with maintenance staff, the following observation was made:

a. The exit discharge lighting calculations indicate the foot candle requirements were calculated to 30 feet from the building or to the public way. CMS requires exit discharge lighting be calculated to 50 feet from the building or to the public way.

Based on observation and/or review of records the facility failed to provide written documentation regarding fire drills in accordance with the LSC section 19.7.1.2.

Findings include:

1. On 4/20/10 between approximately 10:00 AM and 12:00 PM during a review of records with maintenance staff, the following observation was made:

a. The 3rd shift fire drills were all completed between 12:35 AM and 1:15 AM. Fire drills are required to be held at unexpected times under varying conditions.

Based on observation the facility failed to provide approved supervision for sprinkler valves in accordance with the LSC section 9.7.2.1.

Findings include:

1. On 4/20/10 between approximately 10:00 AM and 12:00 PM, the following observation was made:

a. The annual fire sprinkler report from 10/6/09 indicated the main control valves were not connected to a supervisory tamper switch.

Based on observation and/or review of records the facility failed to provide an automatic fire sprinkler system that is maintained and/or tested in accordance with the LSC sections 19.7.6, 4.6.12, 9.7.5.

Findings include:

1. On 4/20/10 between approximately 1:20 PM and 4:30 PM during an inspection of the facility with maintenance staff, the following observations were made:

a. At approximately 1:20 PM, Room 2-089 was observed to have two sprinkler heads with paint on the deflectors.

b. At approximately 1:26 PM, Room 2-096 was observed to have two sprinkler heads with paint on the deflectors.

c. At approximately 1:39 PM, Room 2-131 was observed to have an open penetration through the ceiling tile, above the IT equipment tower, that was not properly sealed. This unsealed opening would allow heat to escape into the void space above the ceiling which could negatively affect the timely operation of the fire sprinkler system.

d. At approximately 1:57 PM, Room 1-019 (Nuclear Medicine) was observed to have a sprinkler head located in the ceiling, behind the corridor door, that was missing an escutcheon plate.

e. At approximately 2:22 PM, Room 1-102 was observed to have a sprinkler head that was still in the pendant position for a drop ceiling that had been removed. The removed ceiling tile and grid exposed a large area above the existing pendant sprinkler head that was not protected.

f. At approximately 4:12 PM, Room G-057 was observed to have a sprinkler head with paint on the deflector.

g. At approximately 4:30 PM, Room G-052 had a sidewall sprinkler head installed. There were no sidewall sprinkler heads in the spare sprinkler box located in the riser room.

Based on observation and/or review of records the facility failed to provide cooking facilities in accordance with the LSC section 19.3.2.6.

Findings include:

1. On 4/20/10 between approximately 10:00 AM and 12:00 PM during a review of records with maintenance staff, the following observation was made:

a. The annual kitchen hood suppression system inspection report did not verify that the hood suppression system would initiate a fire alarm upon activation.

Based on observation and/or review of records the facility failed to provide an emergency plan in accordance with the LSC section 9.6.1.8.

Findings include:

1. On 4/20/10 between approximately 10:00 AM and 12:00 PM during a review of records with maintenance staff, the following observation was made:

a. The facility has a policy that does require a fire watch should the fire alarm or sprinkler system be out of service for more than four hours. Their policy follows the Bureau of Fire Services fire watch policy which is applicable to all state regulated facilities. The CMS policy is more stringent. Their policy states that a dedicated staff member shall be assigned to no other duties than conducting rounds in the facility. Further that rounds shall be continual and not hourly as required in the state policy. During a review of the facility's policy it was observed to have hourly checks rather than continuous rounds.

Based on observation and/or review of records the facility failed to provide an emergency plan in accordance with the LSC section 9.6.1.8.

Findings include:

1. On 4/20/10 between approximately 10:00 AM and 12:00 PM during a review of records with maintenace staff, the following observation was made:

a. The facility has a policy that does require a fire watch should the fire alarm or sprinkler system be out of service for more than four hours. Their policy follows the Bureau of Fire Services fire watch policy which is applicable to all state regulated facilities. The CMS policy is more stringent. Their policy states that a dedicated staff member shall be assigned to no other duties than conducting rounds in the facility. Further that rounds shall be continual and not hourly as required in the state policy. During a review of the facility's policy it was observed to have hourly checks rather than continuous rounds.

Based on observation and/or review of records the facility failed to provide protection from the potential hazards of flammable liquids contained in alcohol based hand rub (ABHR)cleaners in accordance with the LSC section 19.3.2.7.

Findings include:

1. On 4/20/10 between approximately 10:00 AM and 12:00 PM during a review of records with maintenance staff, the following observation was made:

a. During a review of records no written policy could be identified that addresses the potential for spill protection from the ABHR dispensers. The policy shall identify who is responsible for inspecting the ABHR units, the frequency of inspections and what should staff do if a unit is leaking.

Based on observation the facility failed to provide corridor doors that would close and resist the passage of smoke in accordance with the LSC section 19.3.6.3.

Findings include:

1. On 4/20/10 at approximately 1:16 PM during an inspection of the facility with maintenance staff, the following observation was made:

a. Room 2-068 corridor door handle stuck in the open position and would not provide a positive latch when the door was closed.

Based on observation the facility failed to provide for the protection of hazardous areas in accordance with the LSC section 19.3.2.1.

Findings include:

1. On 4/20/10 between approximately 1:32 PM and 1:43 PM during an inspection of the facility with maintenance staff, the following observations were made:

a. At approximately 1:32 PM, Room 2-106A was observed to have been converted to a Storage Room. This room is now required to meet the standards for hazardous areas. The wall above the door, on the right side of the room has an open penetration where drywall has been cut away.

b. At approximately 1:43 PM, Room 1-049 corridor door was observed not to self-close to a positive latch.

Based on observation the facility failed to provide approved means of egress in accordance with the LSC section 19.2.2.3, 19.2.2.4.

Findings include:

1. On 4/20/10 between approximately 3:35 PM and 3:53 PM during an inspection of the facility with maintenance staff, the following observations were made:

a. At approximately 3:35 PM, the Stair #4 Ground Level door latching mechanism failed to provide a positive latch when closed.

b. At approximately 3:53 PM, the Central Supply exterior exit door required excessive force to open.

Based on observation the facility failed to provide lighting in accordance with the LSC section 19.2.8.

Findings include:

1. On 4/20/10 between approximately 10:00 AM and 12:00 PM during a review of records with maintenance staff, the following observation was made:

a. The exit discharge lighting calculations indicate the foot candle requirements were calculated to 30 feet from the building or to the public way. CMS requires exit discharge lighting be calculated to 50 feet from the building or to the public way.

Based on observation and/or review of records the facility failed to provide written documentation regarding fire drills in accordance with the LSC section 19.7.1.2.

Findings include:

1. On 4/20/10 between approximately 10:00 AM and 12:00 PM during a review of records with maintenance staff, the following observation was made:

a. The 3rd shift fire drills were all completed between 12:35 AM and 1:15 AM. Fire drills are required to be held at unexpected times under varying conditions.

Based on observation the facility failed to provide approved supervision for sprinkler valves in accordance with the LSC section 9.7.2.1.

Findings include:

1. On 4/20/10 between approximately 10:00 AM and 12:00 PM, the following observation was made:

a. The annual fire sprinkler report from 10/6/09 indicated the main control valves were not connected to a supervisory tamper switch.

Based on observation and/or review of records the facility failed to provide an automatic fire sprinkler system that is maintained and/or tested in accordance with the LSC sections 19.7.6, 4.6.12, 9.7.5.

Findings include:

1. On 4/20/10 between approximately 1:20 PM and 4:30 PM during an inspection of the facility with maintenance staff, the following observations were made:

a. At approximately 1:20 PM, Room 2-089 was observed to have two sprinkler heads with paint on the deflectors.

b. At approximately 1:26 PM, Room 2-096 was observed to have two sprinkler heads with paint on the deflectors.

c. At approximately 1:39 PM, Room 2-131 was observed to have an open penetration through the ceiling tile, above the IT equipment tower, that was not properly sealed. This unsealed opening would allow heat to escape into the void space above the ceiling which could negatively affect the timely operation of the fire sprinkler system.

d. At approximately 1:57 PM, Room 1-019 (Nuclear Medicine) was observed to have a sprinkler head located in the ceiling, behind the corridor door, that was missing an escutcheon plate.

e. At approximately 2:22 PM, Room 1-102 was observed to have a sprinkler head that was still in the pendant position for a drop ceiling that had been removed. The removed ceiling tile and grid exposed a large area above the existing pendant sprinkler head that was not protected.

f. At approximately 4:12 PM, Room G-057 was observed to have a sprinkler head with paint on the deflector.

g. At approximately 4:30 PM, Room G-052 had a sidewall sprinkler head installed. There were no sidewall sprinkler heads in the spare sprinkler box located in the riser room.

Based on observation and/or review of records the facility failed to provide cooking facilities in accordance with the LSC section 19.3.2.6.

Findings include:

1. On 4/20/10 between approximately 10:00 AM and 12:00 PM during a review of records with maintenance staff, the following observation was made:

a. The annual kitchen hood suppression system inspection report did not verify that the hood suppression system would initiate a fire alarm upon activation.

Based on observation and/or review of records the facility failed to provide an emergency plan in accordance with the LSC section 9.6.1.8.

Findings include:

1. On 4/20/10 between approximately 10:00 AM and 12:00 PM during a review of records with maintenance staff, the following observation was made:

a. The facility has a policy that does require a fire watch should the fire alarm or sprinkler system be out of service for more than four hours. Their policy follows the Bureau of Fire Services fire watch policy which is applicable to all state regulated facilities. The CMS policy is more stringent. Their policy states that a dedicated staff member shall be assigned to no other duties than conducting rounds in the facility. Further that rounds shall be continual and not hourly as required in the state policy. During a review of the facility's policy it was observed to have hourly checks rather than continuous rounds.

Based on observation and/or review of records the facility failed to provide an emergency plan in accordance with the LSC section 9.6.1.8.

Findings include:

1. On 4/20/10 between approximately 10:00 AM and 12:00 PM during a review of records with maintenace staff, the following observation was made:

a. The facility has a policy that does require a fire watch should the fire alarm or sprinkler system be out of service for more than four hours. Their policy follows the Bureau of Fire Services fire watch policy which is applicable to all state regulated facilities. The CMS policy is more stringent. Their policy states that a dedicated staff member shall be assigned to no other duties than conducting rounds in the facility. Further that rounds shall be continual and not hourly as required in the state policy. During a review of the facility's policy it was observed to have hourly checks rather than continuous rounds.